Med surg, disabilities, long term, short term, iv therapy, woundcare

Revised */*/****

DRIVING RECORD AUTHORIZATION FORM

Name: Date of Birth Driver’s License #: State of Issue: 1. If you are under 21 years of age, have you been a licensed driver for at least two years? Yes No N/A

2. Within the last three years, have you had any traffic violations or accidents? Yes No If yes, explain below, including date(s) and circumstances.

3. Have you ever been convicted of:

a. Driving under the influence of drugs or alcohol? Yes No b. Leaving the scene of an accident? Yes No c. Reckless driving? Yes No

If yes, explain below, including date(s) and circumstances. As an applicant for employment at BAMSI whose duties may involve driving my own or agency vehicles, I understand that a check of my driving record will occur through AccuSource, Inc., a federally regulated Consumer Reporting Agency that provides consumer reports and investigative consumer reports as defined by the Fair Credit Reporting Act (FCRA) and my driving history will be compared against insurance industry standards and BAMSI Safe Driver policies. An offer of employment may be rescinded if I am not approved as an authorized driver. Once hired, I understand that failure to maintain an acceptable driving record may be grounds for termination of employment. Explanation and dates of traffic violations and/or accidents in the last three years or convictions checked in Question 3 above:

Signature Print Name Date

DocuSign Envelope ID: CC8766AB-8BB6-43D9-B79A-565103790E94 2/16/1951

Donna Dean

Ma

11/9/2023

Donna Dean

X

S73158490

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